Hemostasis is the process of stopping blood loss from damaged blood vessels. It occurs through vascular constriction, formation of a platelet plug, and formation of a blood clot. When a vessel is damaged, platelets are activated and aggregate at the site of injury to form a loose platelet plug. The platelet plug is stabilized through the blood coagulation process, where a cascade of coagulation factors leads to the conversion of fibrinogen to fibrin to form a solid clot. Fibroblasts then invade and organize the clot, permanently sealing the damaged vessel. Precise regulation of coagulation and anticoagulation factors maintains blood fluidity, but allows for rapid clot formation in response to vessel injury.

1. Hemostasis and Blood
Coagulation
Physiology

2. Hemostasis
• The term hemostasis means prevention of blood loss.
• Whenever a vessel is severed or ruptured, hemostasis is achieved by
several mechanisms:
• (1) vascular constriction,
• (2) formation of a platelet plug,
• (3) formation of a blood clot as a result of blood coagulation, and
• (4) eventual growth of fibrous tissue into the blood clot to close the
hole in the vessel permanently.

3. 1. VASCULAR CONSTRICTION
• Immediately after a blood vessel has been cut or ruptured, the trauma to the vessel wall
causes smooth muscle in the wall to contract; this instantaneously reduces the flow of
blood from the ruptured vessel.
• The contraction results from
• (1) local myogenic spasm,
• (2) local autacoid factors from the traumatized tissues and blood platelets, and
• (3) nervous reflexes.
• The nervous reflexes are initiated by pain nerve impulses or other sensory impulses that
originate from the traumatized vessel or nearby tissues.
• However, even more vasoconstriction probably results from local myogenic contraction
of the blood vessels initiated by direct damage to the vascular wall.
• And, for the smaller vessels, the platelets are responsible for much of the
vasoconstriction by releasing a vasoconstrictor substance, thromboxane A2.
• The more severely a vessel is traumatized, the greater the degree of vascular spasm.
• The spasm can last for many minutes or even hours, during which time the processes of
platelet plugging and blood coagulation can take place.

4. 2. FORMATION OF THE PLATELET PLUG
• If the cut in the blood vessel is very small—indeed, many very small
vascular holes develop throughout the body each day—the cut is
often sealed by a platelet plug rather than by a blood clot.
• To understand this process, it is important that we first discuss the
nature of platelets themselves.

5. Physical and Chemical Characteristics of
Platelets
• Platelets (also called thrombocytes) are minute discs 1 to 4 micrometers in diameter.
• They are formed in the bone marrow from megakaryocytes, which are extremely large hematopoietic cells in
the marrow; the megakaryocytes fragment into the minute platelets either in the bone marrow or soon after
entering the blood, especially as they squeeze through capillaries.
• The normal concentration of platelets in the blood is between 150,000 and 300,000 per microliter.
• Platelets have many functional characteristics of whole cells, even though they do not have nuclei and
cannot reproduce.
• In their cytoplasm are
• (1) actin and myosin molecules, which are contractile proteins similar to those found in muscle cells, and still
another contractile protein, thrombosthenin, that can cause the platelets to contract;
• (2) residuals of both the endoplasmic reticulum and the Golgi apparatus that synthesize various enzymes
and especially store large quantities of calcium ions;
• (3) mitochondria and enzyme systems that are capable of forming adenosine triphosphate (ATP) and
adenosine diphosphate (ADP);
• (4) enzyme systems that synthesize prostaglandins, which are local hormones that cause many vascular and
other local tissue reactions;
• (5) an important protein called fibrin-stabilizing factor, has a relation to blood coagulation; and
• (6) a growth factor that causes vascular endothelial cells, vascular smooth muscle cells, and fibroblasts to
multiply and grow, thus causing cellular growth that eventually helps repair damaged vascular walls.

6. Contd.
• On the platelet cell membrane surface is a coat of glycoproteins that
repulses adherence to normal endothelium and yet causes adherence to
injured areas of the vessel wall, especially to injured endothelial cells and
even more so to any exposed collagen from deep within the vessel wall.
• In addition, the platelet membrane contains large amounts of
phospholipids that activate multiple stages in the blood-clotting process.
• Thus, the platelet is an active structure.
• It has a half-life in the blood of 8 to 12 days, so over several weeks its
functional processes run out; it is then eliminated from the circulation
mainly by the tissue macrophage system.
• More than one half of the platelets are removed by macrophages in the
spleen, where the blood passes through a latticework of tight trabeculae.

7. Mechanism of the Platelet Plug
• Platelet repair of vascular openings is based on several important functions of the platelet.
• When platelets come in contact with a damaged vascular surface, especially with collagen fibers
in the vascular wall, the platelets rapidly change their own characteristics drastically.
• They begin to swell; they assume irregular forms with numerous irradiating pseudopods
protruding from their surfaces; their contractile proteins contract forcefully and cause the release
of granules that contain multiple active factors; they become sticky so that they adhere to
collagen in the tissues and to a protein called von Willebrand factor that leaks into the
traumatized tissue from the plasma; they secrete large quantities of ADP; and their enzymes form
thromboxane A2.
• The ADP and thromboxane in turn act on nearby platelets to activate them as well, and the
stickiness of these additional platelets causes them to adhere to the original activated platelets.
• Therefore, at the site of a puncture in a blood vessel wall, the damaged vascular wall activates
successively increasing numbers of platelets that attract more and more additional platelets, thus
forming a platelet plug.
• This plug is loose at first, but it is usually successful in blocking blood loss if the vascular opening
is small.
• Then, during the subsequent process of blood coagulation, fibrin threads form. These threads
attach tightly to the platelets, thus constructing an unyielding plug.

8. Importance of the Platelet Mechanism for
Closing Vascular Holes
• The platelet-plugging mechanism is extremely important for closing
minute ruptures in very small blood vessels that occur many
thousands of times daily.
• Indeed, multiple small holes through the endothelial cells themselves
are often closed by platelets actually fusing with the endothelial cells
to form additional endothelial cell membrane.
• Literally thousands of small hemorrhagic areas develop each day
under the skin and throughout the internal tissues of a person who
has few blood platelets.
• This phenomenon does not occur in persons with normal numbers of
platelets.

9. 3. BLOOD COAGULATION IN THE RUPTURED
VESSEL
• The third mechanism for hemostasis is formation of the blood clot.
• The clot begins to develop in 15 to 20 seconds if the trauma to the vascular
wall has been severe and in 1 to 2 minutes if the trauma has been minor.
• Activator substances from the traumatized vascular wall, from platelets,
and from blood proteins adhering to the traumatized vascular wall initiate
the clotting process.
• Within 3 to 6 minutes after rupture of a vessel, the entire opening or
broken end of the vessel is filled with clot if the vessel opening is not too
large.
• After 20 minutes to an hour, the clot retracts, which closes the vessel still
further.
• Platelets also play an important role in this clot retraction.

11. 4. FIBROUS ORGANIZATION OR DISSOLUTION
OF THE BLOOD CLOT
• Once a blood clot has formed, it can follow one of two courses:
• (1) It can become invaded by fibroblasts, which subsequently form connective
tissue all through the clot, or
• (2) it can dissolve.
• The usual course for a clot that forms in a small hole of a vessel wall is invasion by
fibroblasts, beginning within a few hours after the clot is formed (which is
promoted at least partially by growth factor secreted by platelets).
• This process continues to complete organization of the clot into fibrous tissue
within about 1 to 2 weeks.
• Conversely, when excess blood has leaked into the tissues and tissue clots have
occurred where they are not needed, special substances within the clot itself
usually become activated.
• These substances function as enzymes to dissolve the clot.

12. MECHANISM OF BLOOD COAGULATION
• More than 50 important substances that cause or affect blood
coagulation have been found in the blood and in the tissues—some
that promote coagulation, called procoagulants, and others that
inhibit coagulation, called anticoagulants.
• Whether blood will coagulate depends on the balance between these
two groups of substances.
• In the blood stream, the anticoagulants normally predominate, so the
blood does not coagulate while it is circulating in the blood vessels.
• However, when a vessel is ruptured, procoagulants from the area of
tissue damage become “activated” and override the anticoagulants,
and then a clot does develop.

13. Steps of Blood Coagulation
• Clotting takes place in three essential steps:
• 1. In response to rupture of the vessel or damage to the blood itself, a
complex cascade of chemical reactions occurs in the blood involving
more than a dozen blood coagulation factors. The net result is
formation of a complex of activated substances collectively called
prothrombin activator.
• 2. The prothrombin activator catalyzes conversion of prothrombin
into thrombin.
• 3. The thrombin acts as an enzyme to convert fibrinogen into fibrin
fibers that enmesh platelets, blood cells, and plasma to form the clot.

14. • First, prothrombin activator is formed as a result of rupture of a blood vessel or as a result of damage to special
substances in the blood.
• Second, the prothrombin activator, in the presence of sufficient amounts of ionic calcium (Ca++ ), causes conversion of
prothrombin to thrombin.
• Third, the thrombin causes polymerization of fibrinogen molecules into fibrin fibers within another 10 to 15 seconds.
• Thus, the rate limiting factor in causing blood coagulation is usually the formation of prothrombin activator and not
the subsequent reactions beyond that point.
• Platelets also play an important role in the conversion of prothrombin to thrombin because much of the prothrombin
first attaches to prothrombin receptors on the platelets already bound to the damaged tissue.
• Prothrombin is a plasma protein. It is an unstable protein that can split easily into smaller compounds, one of which is
thrombin.
• Prothrombin is formed continually by the liver, and it is continually being used throughout the body for blood clotting.
• Vitamin K is required by the liver for normal activation of prothrombin, as well as a few other clotting factors.
• Fibrinogen is a high-molecular-weight protein. Fibrinogen is formed in the liver.
• Thrombin is a protein enzyme with weak proteolytic capabilities.
• It acts on fibrinogen to remove four low molecular-weight peptides from each molecule of fibrinogen, forming one
molecule of fibrin monomer that has the automatic capability to polymerize with other fibrin monomer molecules to
form fibrin fibers.
• Therefore, many fibrin monomer molecules polymerize within seconds into long fibrin fibers that constitute the
reticulum of the blood clot.
• Blood Clot. The clot is composed of a meshwork of fibrin fibers running in all directions and entrapping blood cells,
platelets, and plasma. The fibrin fibers also adhere to damaged surfaces of blood vessels; therefore, the blood clot
becomes adherent to any vascular opening and thereby prevents further blood loss.

15. Clot Retraction and Expression of Serum
• Within a few minutes after a clot is formed, it begins to contract and usually expresses most of the fluid from
the clot within 20 to 60 minutes.
• The fluid expressed is called serum because all its fibrinogen and most of the other clotting factors have
been removed; in this way, serum differs from plasma.
• Platelets are necessary for clot retraction to occur.
• Electron micrographs of platelets in blood clots show that they become attached to the fibrin fibers in such a
way that they actually bond different fibers together.
• Furthermore, platelets entrapped in the clot continue to release procoagulant substances, one of the most
important of which is fibrin-stabilizing factor, which causes more and more cross-linking bonds between
adjacent fibrin fibers.
• In addition, the platelets contribute directly to clot contraction by activating platelet thrombosthenin, actin,
and myosin molecules, which are all contractile proteins in the platelets and cause strong contraction of the
platelet spicules attached to the fibrin.
• This action also helps compress the fibrin meshwork into a smaller mass.
• The contraction is activated and accelerated by thrombin, as well as by calcium ions released from calcium
stores in the mitochondria, endoplasmic reticulum, and Golgi apparatus of the platelets.
• As the clot retracts, the edges of the broken blood vessel are pulled together, thus contributing still further
to hemostasis.

16. Intravascular Anticoagulants Prevent Blood
Clotting in the Normal Vascular System
• Probably the most important factors for preventing clotting in the normal vascular system are
• (1) the smoothness of the endothelial cell surface, which prevents contact activation of the
intrinsic clotting system;
• (2) a layer of glycocalyx on the endothelium (glycocalyx is a mucopolysaccharide adsorbed to the
surfaces of the endothelial cells), which repels clotting factors and platelets, thereby preventing
activation of clotting; and
• (3) a protein bound with the endothelial membrane, thrombomodulin, which binds thrombin.
• Not only does the binding of thrombin with thrombomodulin slow the clotting process by
removing thrombin, but the thrombomodulin-thrombin complex also activates a plasma protein,
protein C, that acts as an anticoagulant by inactivating activated Factors V and VIII.
• When the endothelial wall is damaged, its smoothness and its glycocalyx-thrombomodulin layer
are lost, which activates both Factor XII and the platelets, thus setting off the intrinsic pathway of
clotting.
• If Factor XII and platelets come in contact with the subendothelial collagen, the activation is even
more powerful.

17. Blood Clot Lysis
• The plasma proteins contain a euglobulin called plasminogen (or
profibrinolysin) that, when activated, becomes a substance called
plasmin (or fibrinolysin).
• Plasmin is a proteolytic enzyme that resembles trypsin.
• Plasmin digests fibrin fibers and some other protein coagulants such
as fibrinogen, Factor V, Factor VIII, prothrombin, and Factor XII.
• Therefore, whenever plasmin is formed, it can cause lysis of a clot by
destroying many of the clotting factors, thereby sometimes even
causing hypocoagulability of the blood.